Luring Doctors And Lawyers To Rural America

This is TALK OF THE NATION. I'm John Donvan, in Washington. Neal Conan is away. A lawyer shortage, really? Well, yes, depending on where you live, and rural America is in some places apparently suffering a lawyer shortage right now, just as it has long been coping with a doctor shortage. Small town life is not selling with certain professions, and in distinct ways communities can be truly undermined by the absence of, say, doctors and lawyers and architects and so on.

South Dakota set out to solve this, its lawyer shortage, by literally offering cash incentives to attorneys, cash in the sense of subsidies, subsidized by the taxpayer, to come, live and work in rural parts of the state. But is that working? And what else are communities trying to do to get professionals to come back?

We want to hear you and your stories. If you have decided to move into a rural area, what swayed your decision? Our number is 800-989-8255. Our email address is talk@npr.org. Later on in the program, what political drama and comedy on television actually gets right?

But first to Rapid City, South Dakota. Joining us now is Patrick Goetzinger. He is a co-chair of the Project Rural Practice Task Force in South Dakota. He is former president of the state bar. He joins us by phone from his office in Rapid City. Welcome, Patrick Goetzinger, to the program.

PATRICK GOETZINGER: Thank you very much, John, happy to be here.

DONVAN: So Patrick, as I just outlined, you've got a state with a lawyer shortage, and you've come up with a plan to lure attorneys into the state. Has it worked? Can you give us an example?

GOETZINGER: Well, let me just give you a little bit of background, John. South Dakota in general doesn't have a lawyer shortage. What we have is an allocation of lawyer problem where we need to recruit lawyers to rural America, to the Main Street rural towns that are the cross-section of South Dakota.

And we've developed a program called Project Rural Practice to address the need of recruiting lawyers to Main Street in rural South Dakota. And the highlight of that plan is the Rural Lawyer Recruitment Bill that was recently passed by the South Dakota legislature, which provides an economic incentive to lawyers relocating to a rural community and qualifies under this legislation for that subsidy.

DONVAN: So Patrick, pick a guy, you don't have to name him, or you can use initials, first name, however you want to do, but pick a guy or woman who said yes, and profile that person for us and the decision-making process.

GOETZINGER: Well, the legislation was just passed this last month. It won't be effective until July 1 of 2013. So we can't point to a success with regard to this legislation. But we can point to other successes as a result of what Project Rural Practice has launched. And we'll take Eric. Eric decided to open up a law practice in small town eastern South Dakota as a result of the things that he learned about what the State Bar of South Dakota, the local community that he relocated to or located to, was able to offer him by way of support in the form of resources through the American Bar Association, through our state bar, through our law school, as well as what incentives, both economic and non-economic, the local community could offer Eric as a result of opening up a shop in Main Street eastern South Dakota.

The thought process for Eric was: What barriers do I need to overcome?

DONVAN: What were they?

GOETZINGER: Well, they were finding an office space, creating a budget for his law practice, finding clients and having the support of established lawyers, veteran lawyers, as mentors to assist him in the myriad of decisions, from law office practice management, to how do I deal with my first divorce, my first probate...

DONVAN: But Patrick, if in fact there's a shortage of lawyers in those rural areas, and I take your point that the cities have lawyers, we're talking about non-city areas, how does a new lawyer get mentored if there are no older lawyers around to kind of show him the ropes?

GOETZINGER: Well, we have technology available to us to help bridge that gap. We have a mentorship program through our Young Lawyers Association that will provide mentors on a daily basis and an as-needed basis. They're just a phone call, an email or just a short ride away in a lot of cases from where that young lawyer has set up shop.

So the mentorship side of it doesn't require you to be physically present given the technology that we have available, and the Internet is a great equalizer to allow us to provide those resources both online, on the phone, through the email, to that young lawyer.

DONVAN: Did you find that in the case of Eric, he was a guy who was just looking for a way to make it work? He was a guy who wanted that kind of community setting, and he was looking to get the problems taken out of the way? Or was he a guy who never would have thought about it, and you kind of needed to show him it can be pretty good?

GOETZINGER: I think Eric falls into the first category, where he wanted to make that rural practice work. He was a small-town individual, came from a small town, and he had a lot of questions and a lot of concern about what it would take to establish a law practice in a small town as a solo practitioner hanging out their shingle.

DONVAN: All right, so let me jump to the guy who - or woman who is from the big city and never gave it a thought. Do you have any hope of and interest in bringing that sort of person in?

GOETZINGER: We do, and the hope lies in the fact that we've received numerous contacts from those very types that you describe, people that live in an urban area that are looking to relocate to the more peaceful, quiet life that they associate with a rural area. And we've got several folks that have contacted us, that have looked at our website, that have explored the opportunity and are going through the decision-making process of what will it take to get that individual to the rural area.

And so we're providing them the nudges both through the profession, the state bar, the law school, the ABA, and the resources we can provide there, and we're also working with our local communities, our county, our school district associations, our municipalities, our economic development arms, for the rural community to provide the incentive at the local level to get that individual to that community.

DONVAN: All right, Patrick Goetzinger is co-chair of the Project Rural Practice Task Force; he is former president of the South Dakota State Bar and joined us from the phone by his office in Rapid City, South Dakota. Patrick, thanks so much for joining us on TALK OF THE NATION.

We're looking also to hear your stories. We're going to have some other experts reflect on your experiences, and I want to go first to a caller with a story to tell. Let's go to Rod(ph) in St. Francisville, Louisiana. Hi, Rod, you're on TALK OF THE NATION.

ROD: Hey John, thanks for having me on.

DONVAN: So what happened?

ROD: Well, I was born and raised in St. Francisville in the '70s. I came up here in the '80s. And I couldn't wait to get out of here. I - a small town was too small for me, to hold me. My sister Ruthie stayed behind and taught in the local school, married her high school sweetheart. I was happy for her, but that wasn't my life.

I went on to a journalism career on the East Coast, in D.C., New York and ended up in Philadelphia. Then my sister Ruthie got cancer at the age of 40, in 2010, and she had never smoked a day in her life, but she had terminal lung cancer. And the things I saw from afar when she was suffering completely changed my heart.

I saw that the social bonds, the tight community bonds that had held me down and held me back when I was a teenager, were the only things holding my family together through my sister's suffering. And after she died, my wife and I said, you know what, we need to be part of this community.

DONVAN: Really?

ROD: And so we moved from Philadelphia to St. Francisville, and I...

DONVAN: So there was something in that community that was not available in the big city that you valued very highly?

ROD: Yeah, community. And I'll tell you, we - the things we loved about the big city - New York, Dallas, Philly, everywhere we lived - were all the amenities, the restaurants, the museums, the bookstores. But what we didn't have was community, not like they do and we do in St. Francisville. And medical care was part of it.

My sister's doctor here in town was a guy named Dr. Tim Lindsay(ph), and he treated her like a member of the family. We wanted him to be our doctor too. We wanted to have that kind of intimate medical care, which is common in this little town.

DONVAN: Rod, let me stop you for just a second because I want to bring in Maria Kefalas, who is a professor of sociology at St. Joseph's University, and she wrote a book called "Hollowing Out the Middle: The Rural Brain Drain and What It Means for America." And she's right now standing by at station WXPN in Philadelphia. Maria, hi, welcome to the program.

GOETZINGER: Thank you for having me, John.

DONVAN: So just listening to what Rod said, you know, there's a little bit of a presumption, I think maybe as the program launches, that it's hard to sell small town life because of - exactly as Rod just said, the lack amenities, the sense of maybe you're in the middle of nowhere. Yet he just put his finger on something really appealing and valuable to him in small town life. So why doesn't that weigh more often? Why is there a brain drain when in fact...

MARIA KEFALAS: Well, because education creates mobility, and so small towns are really good at educating their children, and they really foster a culture of you need to leave here and succeed. And so that's part of their mission. They're really good at raising children to be successes other places. That's something that they accept and really - and celebrate.

Unfortunately, it's been kind of - the result over the last several decades has been community suicide, where they're basically exporting their most academically strong children, and the kids who stay behind tend to be the ones who don't go beyond a high-school-level education.

In the town we wrote about in "Hollowing Out the Middle," not one single kid who had dropped out of high school ever left that county, whereas about 60 percent of the young people who had graduated from the University of Iowa would eventually leave the state. And so - I mean education creates mobility.

DONVAN: I wanted, before we go to the break, just take one more drop back in with Rod. What Maria just pointed out, that in a sense you were educated to get out of town, if you're going to be a success you have to leave town, was that your experience?

ROD: That was my experience. But the thing I did not realize until I got to the middle of my life, I'm 46, and saw suffering, I didn't - my sister's suffering, I never really thought about what would happen to me if I got cancer. Well, you know, I had good insurance, but - provided me by my job, but your insurance company is not going to come sit by the bed and pray with you when you're too sick to get out of bed.

Your insurance company is not going to go pick your kids up from school or take them to school when you're too sick to do that. Only your family and your neighbors will do that, and I found that I needed that in my life. And I ended up writing a book called "The Little Way of Ruthie Leming" about my experience. And I think a lot of people will relate to it.

DONVAN: Rod, did your friends back in Philadelphia, your big city friends, think you were crazy to go back to a little town?

ROD: Interestingly enough, John, I thought that they would, but some of them actually got kind of teary about it, saying I wish I had a town like that to go back to, but I don't because my parents moved around so much, and I don't have those roots. I'm really blessed to have this town to come home to, and I'm blessed that we have the Internet...

DONVAN: Rod, I apologize for interrupting because you were saying something that was very truthful to you, and thank you for sharing that with us. We're going to continue this conversation. Maria Kefalas is going to stay with us, and we want to hear more of your stories, and particularly people who have gone back, like Rod. What got you to go back? So stay with us. This is TALK OF THE NATION, from NPR News.

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DONVAN: This is TALK OF THE NATION from NPR News. I'm John Donvan. Maine is the state with the highest percentage of the population living in rural areas, more than 60 percent according to the census numbers. The District of Columbia, of course, has the lowest: zero. California comes next with just about five percent of the population in what the Census Bureau considers rural areas.

Today we're talking about some of the efforts of rural areas to slow down its brain drain among doctors and lawyers and other professions. So we're curious to know what works in stopping the brain drain. So if you are somebody who has decided to move to a rural area, we want to know what swayed you to do so. Our number is 800-989-8255. Our email address is talk@npr.org.

Our guest is Maria Kefalas. She wrote the book "Hollowing Out the Middle: The Rural Brain Drain and What It Means for America." And Maria, before the break you shared with us some of your thinking on why people are leaving these communities. But I'd like you to take a minute to talk about the impact.

You know, we started the conversation this afternoon by talking about South Dakota having problems with lawyers going to rural areas. And I'll be honest, it struck me as not a huge problem, but now I think I'm wrong. What happens to a community that doesn't have lawyers?

KEFALAS: Oh, a community without lawyers cannot do divorces, they cannot do probate, they cannot manage business transactions, and I think even more critically for many decades we've been seeing the impact of no physicians and no doctors. Right now in Iowa they've been piloting e-mergency rooms, where they staff, you know, hospitals that no longer have doctors with nurses, who then use Cisco technologies to basically triage these patients who comes into these hospitals, and doctors examine them by looking at them through computer networks.

It is really devastating, and towns will die. It's part of the process of the death of the community. I don't think the absence of lawyers kills communities, but it's one of the symptoms, and - yeah.

DONVAN: You know, it occurs to me that people may kind of routinely criticize both the medical profession and the legal profession, and they do, but at the same time, was there not a tradition in this country, in small towns and large, that doctors and lawyers were in some sense pillars of the community, they represented - go ahead.

KEFALAS: Oh no, I'm sorry, absolutely, absolutely, and really we start to see this shift in the mid-20th century, where there's an equal kind of split between the small population of college-educated people, that they're as likely to live in a rural area as an urban area. By the mid-20th century, that really shifts, and certainly in the '80s we start seeing the rise of the so-called creative class.

And Chicago and the Twin Cities boomed because all over the Great Plains and the Dakotas, they were exporting these kids in huge numbers. And so Austin boomed, and the Twin Cities, and Chicago boomed, and Boston boomed. But it was because they were sending talented, educated kids outside the rural regions into urban areas. And it's a very powerful economic reality that pushes young people to do this.

And part of the difficulty with these initiatives is that I've never seen one work. I've seen everything from current Secretary Vilsack, when he was governor of Iowa, he went on the walking tour of Iowa, where he tried to host - he went and hosted cocktail parties in D.C. and New York and tried to recruit University of Iowa alums to come back. And I think they enjoyed the free Merlot, but they didn't come back to Iowa.

DONVAN: Do you know why?

KEFALAS: Well because it was - the reasons young people come back are mostly emotional, just like the previous guest talked about. They fall in love, or they - they make a decision to give up the big-city incomes, the big-city life, and they make a conscious decision to start a life in their rural communities, maybe where they have connections to, usually. And - yeah, go ahead.

DONVAN: Maria, the reason I want to stop at this point is because we're right now talking about programs not working, and I want to bring in Byron Crouse, who is program director at the Wisconsin Rural Physician Residency Assistance Program. Byron joins us by phone from his office there. Byron, welcome to the program.

BYRON CROUSE: Thank you very much, John, appreciate the opportunity to share some perspectives with you also.

DONVAN: Do you have success stories? I know your focus is on bringing doctors to rural areas. Do you have successes?

CROUSE: We do, and I would have to agree with some of the comments that Maria was making also about the impacts that health and the health system has on a rural community. Often we see our providers in the health system being if not the leading, it's the second- or third-leading economic engine in these communities. And if you have a community that is paying into the health insurance, but that health care is being delivered elsewhere, those are monies that are leaving that community.

If you have physicians in the area, they draw and increase the vibrancy of the economy in that community. There's a multiplier effect (unintelligible) very vibrant. So what we've been looking at in Wisconsin is trying to identify and select those students with the greatest propensity to return to the rural communities and continue to nurture that rural interest during their medical education, both in medical school and residency.

DONVAN: How do you do that?

CROUSE: We have programs that really have taken - kind of tracks where the students - we identify students from rural communities, with commitment to rural communities, with engagement in rural communities. So there's an admissions process that brings the right people in, into the education programming.

And then we keep them in the rural communities for rotations, developing the strength in the rural communities for educational opportunities so they get back to the rural communities during their education.

DONVAN: Byron, one of the thing - again, this may just be my pre-judging the situation, but I'm assuming when you're fishing for these students, maybe you don't like that word, let me think of another word, appealing to students to come to rural areas, are you looking for family doctors and internists, you know, doctors who can handle a wide range of medical challenges, or are you actually looking for, you know, the guy who just does knee surgeries or extreme specialists?

CROUSE: Excellent question because, I mean, traditionally when we are looking at rural areas, there is no question the demand, the greatest demand in a rural community in Wisconsin and throughout this country is in primary care and family medicine. But as I talk with our hospitals and clinics throughout the rural regions nationwide, you know, they quickly point out but we also need our general surgeons. We need radiology. We need the support of all specialties. But the greatest demand is in primary care.

Another question that I commonly get is: What's the difference between the general surgeon or the radiologist in rural versus urban areas? And you hit the right word, you know, the breadth and the scope of practice. Whatever specialty they're in, they need to be practicing the full scope of that practice and not just a limited, partial, like a component of their various specialty. So we need all areas.

But what we've found is we bring students in that have a commitment and an engagement in the community, keep them in those areas during the training, and they return to those areas.

DONVAN: Do you have enough?

CROUSE: We're still trying to grow that. You know, unfortunately we're starting in a deficit. You know, as we speak today, we're dealing with, in Wisconsin alone, probably 150 to 200 physicians in our rural areas that we could place today. If we could bring a busload in, we'd be able to place those people. And with a projected growth of the elderly population, the expansion with the Accountable Care Organizations, rather the ACA for increased insurance, that demand is going to increase. And so we have an uphill battle to be working on meeting the need that exists and will be growing.

DONVAN: Byron, I want to bring some more of our listeners in. I want to go to Rick(ph) in Brookings, South Dakota. Hi Rick, you're on TALK OF THE NATION, and tell us about Brookings. Is it rural?

RICK: Hi, thanks for taking my call. The gentleman from Wisconsin is right on the mark. The need is fulfilled when you bring kids from those areas to med school and train them so that they can - they're going to be the ones to go back. You're just not going to bring the big-city ever out to De Smet and Arlington and, you know, Chamberlain.

DONVAN: You think that's just a lost cause, that that's just not going to be your pool of...

RICK: It shouldn't be because the quality of life here is fabulous, and the opportunity to practice the kind of medicine you want to practice is wonderful here.

DONVAN: Are you a doctor yourself?

RICK: I'm a general internist, yeah, outpatient and hospital general internist. And, you know, I even have an NPR television show. You can do almost anything when you're from a rural area and make it happen. I'm on South Dakota Public Broadcasting on Thursday nights.

DONVAN: So Rick, you may not have asked me - I just asked you to take a sentence or two before to tell us about Brookings. Are you out in a rural area right now?

RICK: Well, Brookings is an SPSU, the home of the South Dakota Jackrabbits. But it's less than 20,000 without the college. And it is a - And I'm from De Smet, a little town on the prairie, home of Laura Ingalls Wilder. This is the area of the country where there's great pheasant hunting, great fishing, and it's rural. It's rural South Dakota.

We take care of the farmers and the people of the prairie here. This is rural South Dakota.

DONVAN: Maria, we've been talking for the last few minutes about the medical model, and is the medical profession a little bit ahead of everybody else, certainly ahead of the lawyers in this effort to bring people into rural communities?

KEFALAS: I don't think so. I think that they just had - they've been dealing with it for decades, and I think that they are now reaching a real tipping point where I think - I work in communities in Iowa where the existence of the hospital and the threats to the hospital shutting down were absolutely viewed as the end of the community. So people are really trying to figure out a way to deal with this problem as the populations age and as the - as I think we reach a new level of crisis in terms of care.

I think the lawyers are new, but they're probably going to have the same kind of challenges. And my concern about doing this, it's really hard to do, because the reasons that I found that young people came back were really emotional and very private issues. And it's...

DONVAN: Yeah. I feel like that's what we're hearing so far.

KEFALAS: Yeah.

DONVAN: And people who say they've gone back, they had a connection. It's not that some package of incentives made some big city slicker change his mind. I'm going to go live in a rural - small town. It's either there - it sounds like it's either in you, or it's not.

KEFALAS: Yeah. And actually, the - I think that it's wonderful to do, and I think there's maybe one way to do it. One way to do it would be to really relieve the debt burdens that students are carrying and use that as, in a way, to incent them in. So these young doctors are graduating from medical school with huge debt, and that would be a way to maybe get - turn their heads.

The other incentive - and this is going to be really shocking - the only source of population that I can point to that definitively transforms communities and deals with these issues are immigrants. So recruiting highly educated immigrants, which is what actually many states have tried to do quietly before - you know, there were huge battles internally over this - was to bring in immigrant professionals.

And that may not work with lawyers, who have to go through an American university, but certainly that has been the case with medical personnel. So I think you want to do a multipronged approach of going after your own young people and really courting them, as Wisconsin's doing, to try to get them back, understanding that it's going to be an uphill battle a lot of the time.

And the second part of that is really looking at immigrants, because I can point to lots of communities in the United States, rural communities that have exploded with the arrival of immigrants. But it takes national policy and federal immigration reform for that to happen. But a lot of governors quietly admit that this is their secret weapon, but it's a nuclear option. It's very unstable. It's hard to do, too. But it does work.

DONVAN: Let's bring in Nicole(ph) from Waynesboro, Pennsylvania. Hi, Nicole. You're on TALK OF THE NATION.

NICOLE: Hi. Thank you for taking my call.

DONVAN: Sure. What's your story?

NICOLE: Well, I - I'm a teacher in a small town in southern Pennsylvania. My husband and I are both teachers, and we're actually getting ready to move from our small town where I was born and raised and my whole family is located to a more urban area, because there are no jobs in our area right now.

We each drive 50 minutes to work a different way, and the pay scale is very low. We don't get reimbursed for our master's degrees, which we're required to get continuing education. So, unfortunately, for us, economically, we just can't survive in my town anymore, so we're leaving our family and packing up our kids and moving.

DONVAN: And you're doing so with regret.

NICOLE: With - yes. With a lot of regret, actually. Like I said, my entire family lives in this area. I went to school there. It's a beautiful area. It's close to a lot of things. But I will never pay back my student loans if I continued to work in this area, driving 50 minutes to my job. And there's no way - there's no upward mobility for me as far as my profession goes. There's no way for me to develop professionally in my town.

DONVAN: All right, Nicole. Thanks very much for sharing your story, which...

NICOLE: Thanks for taking - thank you.

DONVAN: Yeah, you really got the sentence for us on what the disincentives are.

CROUSE: John?

DONVAN: Just one second, Byron. I just need to...

CROUSE: Yeah.

DONVAN: ...say this to our listeners, that you're listening to TALK OF THE NATION, from NPR News.

OK, Byron. Go ahead.

CROUSE: John, I would like to emphasize, I think the point that our last caller just made, I think, is a real important one, too. We need to differentiate between recruitment and retention into our rural areas. Money will bring people in. It will keep them there for a short period of time.

But particularly in the health care area, retention is really critical in terms of the continuity of care, the continuity and the engagement with patients over time, particularly when we're dealing with populations now that have more chronic disease and need that long - longer-term, sustained relationship with their providers.

Maria kind of talked about, you know, some of the issues with the international providers, health care providers being used as a source to help with rural areas. And, indeed, a program called the J-1 Visa Waiver Program helped keep international graduates of the training programs in rural and underserved areas.

But there's a lot of national and international pressure kind of talking about we're just training - addressing our rural brain drain with now a global brain drain, as we are depleting other nations and Third World countries of their workforce needs and providers.

Work out of Pennsylvania with Howard Rabinowitz and others have really looked at programs such as we're doing here in Wisconsin with our WRPRAP program, or the Wisconsin Academy for Rural Medicine, what they're doing in Pennsylvania and other areas - even though they take a small percentage of the total medical school class size - make a significant impact on the workforce in rural areas with providers, and have a better retention rate in those areas when they get people that really engage in the community rather than never really quite fit in.

And once their obligation - whether it be financial or other visa-driven obligations - end, they then leave that community, and you have this cyclic turnover of providers that also, you know, leads to a deterioration of the confidence and quality in the health care system in a rural area.

DONVAN: And, Maria, you title your book "Hollowing Out the Middle." And is that the trend? In fact, is the hollowing continuing?

KEFALAS: Oh, yes. And I think that - it's been interesting, though, in Iowa that has sort of been reclaimed recently as the Silicon Prairie. They have been, I think, very proactive in trying to attract industries that will take advantage of their labor force. And Iowa always kind of reminds me of Ireland in the old EU and the Celtic Tiger in the fact that they have an excellent labor force in their educated young people. Their - even their kids with high school diplomas in community college degrees have really great skills, and they've been really very savvy about connecting community college programs to existing need. And one of the other ways to go about this, as well, is community college students remain.

And one of the things I've often talked about is that when your community college students are your population mostly likely to stay, looking at ways to use those community colleges to train medical professionals - not, obviously, going to be MDs, but physician's assistants and nurses that can, with training and expanded roles, take on a lot of the responsibilities held by conventional doctors. And we're seeing that in urban centers like Philadelphia. People go in for very complex procedures, and it's all done by technicians and nurses.

DONVAN: Well, there's...

KEFALAS: So I think that's also a potential because our - the community college kids do remain.

DONVAN: Thanks very, very much. Maria Kefalas is a professor of sociology at St. Joseph's University and author of "Hollowing Out the Middle: The Rural Brain Drain and What It Means for America," and Byron Crouse, professor of family medicine and associate dean for rural and community health at the University of Wisconsin. Thanks both of you for joining us on the program. Up next, the new ear of political TV. Politicians, what do you think you see of yourselves on those new shows? Does it ring true? Our number is 800-989-8255. It's TALK OF THE NATION, from NPR News. Transcript provided by NPR, Copyright NPR.